A deadly and somewhat mysterious infectious disease has invaded America in the person of a foreign traveler. The local management and the global magnitude of the epidemic are so dire that the President of the United States cuts short his political travel schedule and rushes back to the White House to manage the contagious crisis.
No, I’m not talking about the Ebola crisis of 2014. I’m talking about Asiastic cholera crisis of 1892—an afterthought in the history books, but a story that offers some valuable lessons for today.
It’s been more than a hundred years, so a lot has changed. Medical science is much more advanced. The world is a more interconnected place. But there are some important parallels between now and then. In some respects—the fear of travelers carrying the disease, the intense criticism of public health authorities—things haven’t changed much at all.
Asiatic cholera was spread by body fluids—especially the copious diarrhea it produced to the point of dehydrating a grown man in a matter of hours. Indeed, to the nineteenth-century American, cholera was every bit as scary, deadly, and disgusting as Ebola fever is today. The cholera of 1892 had already decimated much of India, the Middle East, Asia, and Eastern Europe and shut down the port of Hamburg, the largest in the world. By August 30, New York City, the world’s second largest port, began to receive its first cholera victims, mostly impoverished Russian Jewish immigrants.
That evening, President Benjamin Harrison was dining at the Westchester County estate of his running mate, Whitlaw Reid. During the soup course, he received a telegram from Washington urging him to return immediately and take charge of the epidemic. Griping about the rigors of his job, the president commandeered Reid’s best surrey, horses, and driver to take him to the White Plains train station. The coachman took a shortcut along a “hilly, wooded, dark and dangerous” road. Along the way, one of the horses suddenly shied and the coach veered off the road, throwing the president in “a heap from the wagon.” Slightly shaken, bruised, and soiled, Harrison leaped back into the carriage and ordered the driver to continue. A special train, rolling at a “mile a minute,” sped the bedraggled president to Grand Central Station, and from there the chief executive took the presidential train, the Nimrod, back to the nation’s capital. He was at his desk bright and early on the morning of September 1 to discuss the cholera crisis with his cabinet and his beleaguered surgeon general, Walter S. Wyman.
Aware of the upcoming presidential election, Harrison avoided the politically sensitive issue of immigration restriction and the even more sensitive questions of state versus federal authority in public health matters. Instead, the president encouraged individual states to develop their own containment protocols. Realizing there would be too little uniformity with such a plan, Harrison buttressed this arrangement with a federally mandated 20-day quarantine of all steerage passenger immigrants (but not those traveling in the higher priced cabin class). Harrison described the “undesirable” Jews escaping the disease and strife of Czarist Russia for America as a “direct menace to the public health.” Harrison’s order evolved into the National Quarantine Act of 1893, which gives the president the power to contain an epidemic crisis—although local, state and federal officials continued to disagree about the boundaries of the authority, and, to this day, no other president has invoked the law’s powers.
Throughout September of 1892, thousands of immigrants and cabin class passengers were medically inspected and quarantined. Although more than 100 passengers died of cholera en route from Hamburg to New York only nine cases were discovered in New York City. No one ever figured out exactly how cholera jumped from the harbor into Manhattan, yet it was these nine cases that filled the American newspapers—rather than the hundreds of thousands of people who had already died in India, Asia, and across Russia.
The cholera crisis had revealed weaknesses in the public health infrastructure. But interest waned as the scare faded into memory and Harrison lost his presidency to a resurgent Grover Cleveland. The overflowing quarantine station near Staten Island and other stations like it across the nation were neither upgraded nor staffed with enough doctors, a perennial problem that hindered the epidemics that followed. Local hospitals and their staffs went back to taking care of the diseases they were used to seeing, instead of adequately planning and training for the next contagious crisis. And too few Americans thought to do anything about improving the living conditions in Asia, India, and the Middle East, where so many pandemics of that era began.
Today policymakers are weighing different options, including quarantines and outright travel bans, for trying to limit the spread of Ebola. Those decisions will (and should) depend heavily on the specific clinical characteristics and scientific knowledge of Ebola and how it’s spread so far. But the cholera experience provides some important insights.
It’s probably true, for example, that in 1892 the 20-day quarantine helped by reducing the flow of immigrants and the overwhelming workload of medical inspection. But the quarantine also caused collateral damage—starting with the scapegoating of all Eastern European immigrants. Meanwhile, those of us who have studied the outbreak have concluded that it was not the quarantine that deserves most of the credit for containing the disease. It should go instead to public health officials in New York City and to the federal government. They worked aggressively to ensure that the water supply was not tainted with the cholera microbe—and used case tracing and isolation of the ill to keep the disease from spreading.
These steps almost certainly prevented a major cholera outbreak in the city and, eventually, the nation. That doesn’t mean travel restrictions today make no sense. It does mean policymakers should carefully think through the pros and cons—and design their interventions with the specifics of this terrible infectious disease in mind. For example, there may be a case for a “modified” quarantine, under which visitors from affected areas or those with direct contact with the ill would self-monitor their health and report results from home with frequent examinations and conversations with health care professionals as well as every possible means to ameliorate their fears and isolation. Those who develop symptoms of Ebola should immediately be cared for and transferred safely to one of the four high-tech bio-containment units the federal government funded at NIH in Bethesda, at Emory University in Atlanta, the University of Nebraska in Omaha, and St. Patrick Hospital in Missoula.
Other elements of the current crisis have an even more familiar feel. There's still confusion about where local and state authority over public health ends, and federal authority begins. Commentators today are scapegoating public health officials—complaining about the “unacceptability” of the three cases in Dallas, just as they did about the nine cases of cholera in New York City in 1892. Nobody seems to appreciate the remarkable speed with which Dr. Thomas Frieden and staff at the Centers for Disease Control have isolated and used contact tracing to identify everybody who is at risk of getting the disease. The media conversation also gives short shrift to the real tragedy unfolding—the one in Africa, where Ebola has already killed thousands and is likely to kill many, many more. The U.S. and other wealthy nations could be doing a lot more to fight the disease there. But there’s no similar outcry for that kind of action.
History teaches us that once the Ebola crisis subsides, we will likely revert to the same practices and conditions that gave rise to the Ebola epidemic in the first place. But it doesn’t have to be that way. Once we get our own Ebola threat in check, we must commit to a major and lasting effort in Africa—first to defeating Ebola where it is currently killing thousands, and then to building up infrastructure that can help fight the next epidemic there. Historians don’t often think of Benjamin Harrison as a president with an unfinished legacy or much of a legacy at all. But there’s work to be done—and maybe President Obama can do it.